Book Appointment l Fine Arts Dentistry

Your dental health is important, so we make it a top priority at Fine Arts Dentistry in Matthews.

First Name*
Last Name*
Date of Birth*
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Are you a new patient or existing patient?*
If patient is a minor
Responsible Party full name:*
Date of Birth*
MM slash DD slash YYYY
Relationship*
Best Days and Times
Appointment Date*
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Time*
Appointment Date
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Time
Appointment Date
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Time
Contact information
Email*
Phone Number*
Reason for appointment:*
How did you hear about us?*
Insurance Info
Primary insured full name as shown on policy*
Primary insured date of birth:*
MM slash DD slash YYYY
Insurance Company:*
Employer (if plan is sponsored through work):*
Telephone number (usually found on the back of the card):*
Subscriber or member ID (or social security number):*
Group # (if applicable):*
Health Questionnaire
Please list any allergies or medical conditions you have:*
Please describe specific concerns you have regarding your dental health, if any:*
When was your last dental cleaning (approximation is acceptable)?*
Please list the telephone number and address of your preferred pharmacy, if applicable.*
PLEASE NOTE: If you have had any x-rays taken elsewhere in the last 12 months: Contact your previous dental office to request that they send ALL xrays to patelalstonandassociates@gmail.com prior to your dental appointment to avoid unnecessary out of pocket costs.
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